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Ben-Yishay, Y., & Daniels-Zide, E. (2000) - Examined Lives - Outcomes After Holistic Rehabilitation.
Ben-Yishay, Y., & Daniels-Zide, E. (2000) - Examined Lives - Outcomes After Holistic Rehabilitation.
This article poses the question whether the attainment of optimal outcomes
following neuropsychological rehabilitation requires that the individual achieve an
"examined self." The author answers the question in the affirmative and provides
data from a retrospective pilot study to substantiate his claim. Implications from the
findings are briefly discussed.
I feel honored to have been asked to deliver the Leonard Diller Lecture. Leonard
Diller is universally respected. As a man who has been working with him closely
for 36 years, I can say, to paraphrase the song, "If you knew Lenny like I knew
Lenny," you would respect and love him even more. Lenny earned his reputation
and the esteem in which he is held the old-fashioned way: with absolute integrity;
a penetrating, analytical mind; scholarship; wisdom; and the absence of a mean
bone in his body. This presentation reflects both his and my long-standing interest
in issues concerning our field, other than how to deal with HMOs.
Initially, Lenny was unaware of the purpose for which I and my colleague,
Ellen Daniels-Zide, undertook the retrospective pilot study which I shall shortly
present here. This gave me the opportunity to use him as a sounding board, as I
Yehuda Ben-Yishay and Ellen Daniels-Zide, Brain Injury Day Treatment Program,
New York University—Rusk Institute.
This article was delivered, with minor modifications, as the Leonard Diller Honorary
Lecture at the 106th Annual Convention of the American Psychological Association,
Boston, August 22,1999.
We express our thanks to Stanley Ferneyhough for performing the statistical analyses
on short notice.
Correspondence concerning this article should be addressed to Yehuda Ben-Yishay,
PhD, New York University Medical Center, 660 First Avenue, New York, New York 10016.
Electronic mail may be sent to Yehuda.Ben-Yishay@med.nyu.edu.
112
Rehabilitation Psychology, 2000, Vol. 45, No. 2, 112-129
Copyright 2000 by the Educational Publishing Foundation, 0090-5550/00/$5.00 DOI: 10.1037//0090-5550.45.2.112
Examined Lives 113
have done for 36 years. Thus, once again, I have been the beneficiary of Lenny's
unique way of helping me see how our work fits into the larger picture of what is
going on at present in the field of psychology. Here is one illustration of Lenny's
subtle way of expanding my horizons.
"So what are you thinking about nowadays?" Lenny asked me several weeks
ago. "I am thinking about conducting a retrospective pilot study," I replied. "I
would like to find out whether we may be able to distinguish between those
graduates of our program whom I previously (Ben-Yishay, 1993) described as
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having been successful, before they were discharged from our program, in
reconstituting their ego identity (in the Eriksonian sense of having made explicit,
self-defining statements) and those graduates who, by the time of discharge, had
adjusted quite well to their disability but gave no overt signs that they, too, had
reflected on their sense of identity, as had the former."
"What intrigues me," I told Lenny, "is that both subtypes of graduates
subsequently achieved a stable personal and vocational adjustment which persists
to the present day. So the question is, other than living up to the admonition of
philosophers that one should strive to achieve and lead an examined life, have
those lucky "self-examined" graduates gained any particular advantage over
those who merely "adjusted" in terms of practical, post-rehabilitation outcomes
such as their personal, social, and vocational adjustment and the overall quality of
their life?" "But how are you going to test this question?" Lenny asked (knowing
full well that only 25% to 30% of our graduates live close enough to our facility to
be capable of being interviewed in person). "I will select a small sample of
successful graduates of both types, and ask them, over the phone or in person, to
rate themselves on a 10-point scale, in the six areas which are outlined in
Table 1."
After mulling it over a while, Lenny said: "So you are taking this one step
beyond the concern with the ecological validation of the program outcomes
(Rattock et al., 1992). You are into the realm of wellness issues." Next day, I
received from him, through the in-house mail, several articles. These included the
transcript of Seligman's (Proffitt, 1999) lengthy interview with the Los Angeles
Times in which he spells out the major premises of "positive psychology": that if
you teach people to be optimistic and resilient, they are less likely to suffer
depression and will lead a productive life, and that optimism and self-esteem go
hand-in-hand. Included were reprints of three articles. The first was a study by
Green and associates (Green, Bailey, Zinser, & Williams, 1994), who found that
self-acceptance and self-esteem were good predictors of academic performance.
The second article (Ryff & Keyes, 1995) identified six dimensions of wellness:
autonomy, environmental mastery, personal growth, positive relations with oth-
ers, purpose in life, and self-acceptance. In the third paper, Schmutte and Ryff
(1997) point to some interesting relationships between personality dimensions,
such as low neuroticism, extroversion, and conscientiousness, and dimensions of
well-being, such as self-acceptance, environmental mastery, and purpose in life.
After I read these interesting papers (Lenny reads everything and remembers
114 Ben-Yishay and Daniels-Zide
anything that is relevant to the topic at hand), I told him: "You are right, we are
indeed into examining questions of wellness!"
Before I present the results of our retrospective pilot study, I must briefly
define ego identity and outline the key ideas of Kurt Goldstein concerning the
rehabilitation of persons with a brain injury. Goldstein's ideas have guided the
approach as well as the remedial and therapeutic techniques which have been
developed by our program.
imitation, as when a little girl scolds her doll in the way she herself is scolded, but
without adopting her mother's mannerisms" (Yankelovich & Barrett, 1970, p.
123). A critical phase of the imitative aspects of ego identity takes place during
adolescence, at which time "the synthesizing ego, acting on the sum of all of these
partial processes, consolidates them, forges them into a unity, and transforms
them to create the unique sense of self known as Ego Identity" (Yankelovich &
Barrett, 1970, p. 124). However, in order to achieve an authentic ego identity,
these fused and internalized meanings must become a part of the person's inner
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being.
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me most was the loss in these men of a sense of identity. They knew who they
were; they had a personal identity. But it was as if subjectively their lives no
longer hung together—and never would again" (p. 38). This is in line with
Laing's (1962) observation that the (Eriksonian) sense of self is capable of
dissolution in certain pathologic conditions, manifesting itself as generalized
feelings of unreality; a blurred sense of selfhood, only precariously differentiated
from the rest of the world; a lack of temporal continuity; and feelings of
emptiness. Those of us who work with individuals with brain injury frequently
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
observe either what appears to be a total dissolution or, at the least, a severely
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nity" structure (Ben-Yishay et al., 1978, 1985; Ben-Yishay, 1999; Ben-Yishay &
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Gold, 1990; Ben-Yishay & Lakin, 1989; Ben-Yishay & Prigatano, 1989; Zide &
Ben-Yishay, 1999; Ben-Yishay & Diller, 1981), combined with its specially
developed cognitive and therapeutic remedial techniques (Ben-Yishay & Diller,
1983; Ben-Yishay, 1978-1983; Ben-Yishay & Gold, 1990; Prigatano & Ben-
Yishay, 1999), help achieve the "transformation of the individual's personality [to
enable him or her] to bear restrictions" that Goldstein (1959, p. 10) considered
essential to enable a person with a brain injury to feel that he or she is healthy
again.
METHOD
Participants
From the master list of our 300 graduates to date, we selected about two dozen
individuals whom we designated as "self-examined" and an equal number of
individuals whom we designated as "adjusted." (The criteria for designating an
individual as either self-examined or adjusted are outlined further below.)
Because of time constraints, we decided to limit the number of subjects in each
group to the first 12 who could be interviewed at the appointed time. We selected,
for either group, only subjects who are known to us to have had an uninterrupted
work adjustment since their discharge from our program. Of the total 24
participants in this study, 8 were seen in person, 4 of whom belonged to the
self-examined group and 4 to the adjusted group. The others were interviewed by
phone.
Procedure
a lot of street smarts. My brain injury gave me a lot of deficits, but I remain smart;
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injury. After 10 months in our program, J., helped by his strong religious faith,
found a way to make peace with his existential situation. Initially, he resumed
work as a clerk at a health club. About 3 years later, he became employed as an
international telephone operator. Concurrently, he began part-time studies toward
a degree in rehabilitation counseling. After 10 years of persistent studies, J.
graduated and became employed as a rehabilitation counselor at a well-known
rehabilitation center. J.'s end-of-program speech included the following assertion:
"The Lord intended [that I become severely incapacitated] so [that] I can be a role
model [to others] for graceful acceptance." J.'s self-definition (to use the Erikso-
nian concept) was of the "transcendent" variety. Having resolved the question of
why he became the victim of a severely incapacitating motor vehicle accident, J.'s
competitive tendencies were transmuted into a "mission" to serve God by serving
as a role model for acceptance.
Sample 5. C. was a physician and professor at a midwestern school of
medicine. After 1 year of rehabilitation in our program, C. returned to assist
colleagues in research and, somewhat later, also to teach medical students the
clinical art of communicating with patients and their families. C. has authored a
best-selling book on her experiences during rehabilitation and is presently a
much-sought-after speaker on the subject. C.'s speech at the end of the first
20-week cycle of treatments contained the following: "Successful rehabilitation
really means learning to accept myself... it requires me to examine who I am and
come up with a less limiting definition than physician. Regardless of my [future]
vocational potential, I need to expand my identity beyond my life's work." C.'s
reconstituted self-definition revealed a critical "shift": from the prior central
feature of C.'s ego identity ("physician") to (also preexisting) "passions" such as
her love of gardening, poetry, music, and friendships.
Sample 6. M. was a Ist-year college student, on scholarship, when she
became injured. For nearly 3 years postinjury, she struggled unsuccessfully to
resume her college studies. She discharged herself against medical advice from a
rehabilitation program in her state, refusing to own up to her limitations. Attempts
at earning some money as a cashier at a supermarket resulted in failure as well.
Finally, through the active and vigorous intervention of her attorney and with the
support of her mother, M. enrolled into our program. One year later, M. resumed
her college studies, became successfully employed in a clerical capacity, estab-
lished independent living, graduated cum laude from college, and is presently
pursuing graduate studies. M. was a lifelong achiever, scholastically and in sports.
120 Ben-Ylshay and Daniels-Zide
She was a champion long-distance runner during her high school years and at
college prior to her injury. Her speech included the following self-definition:
The old me did strive to be successful in what I did. In my preinjury life, I measured
[success] on a scale geared for speed and agility.... I have had to revise my preinjury
"ruler" to a new, more appropriate measurement for success . . . I will be pleased
[making progress] no matter how small [the steps].... I have the hardy strength and
strong character of a cross-country runner.
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As her statement clearly showed, M.'s struggle to reconstitute her ego identity
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involved, for her, a most difficult and painful process: She had, as she put it, to
adopt a new "ruler" (or yardstick) for measuring success in life. This entailed a
shift from a competitive view (Was she the best student? The fastest runner?) to a
subjective one (i.e., finding meaning and satisfaction in her rehabilitation gains,
no matter how small or slow). To make this transformation, M. invoked two "old"
personality attributes ("hardy strength and the strong character of a cross-country
runner") which, preinjury, served her competitive drive for excellence but, at
present, help her find meaning in her life.
We designated as "adjusted" those individuals who had responded well to the
remedial interventions of the program, endorsed our recommendations concern-
ing the type of work they ought to engage in postdischarge from the program, and
adjusted well to their disability but showed no overt signs of defining themselves
in the Eriksonian sense, and their graduation speeches contained no explicit,
self-defining assertions.
Subjects were told that the purpose of this study was to "find out how you view
your present life." Each was asked to update his or her vocational status and to
rate himself or herself, along a 10-point scale, in the six areas which were outlined
above. The six statements were read slowly, and the best (a rating of 10) and the
worst (a rating of 1) responses were carefully explained to the subjects. Before the
subject provided his or her ratings, we made certain, through use of verification
techniques, that the subject clearly understood the meaning and the intent behind
each of the six statements. Subjects were encouraged to be deliberate and accurate
in their self-ratings.
Having obtained the self-ratings from the 24 subjects, we pulled out from their
charts the transcripts of the final "oral report card" and a copy of our final
discharge report, which were prepared before these subjects commenced their
respective vocational trials. At the end of an individual's treatment, he or she
receives an oral report card. In the presence of peers, significant others, and the
entire staff, the individual is presented with a detailed and carefully nuanced
assessment (arrived at by team consensus) of his or her achievements in the areas
of awareness and understanding of the consequences of the brain injury; mallea-
bility to the remedial interventions of the staff and peers; adequacy and reliability
of application, in one's functional life, of the compensatory skills that were
learned in the program; and acceptance of one's disability. We operationalize
acceptance as (a) a cessation of "mourning" or agitation over the incurred losses,
(b) morale, (c) satisfaction with the outcomes of one's rehabilitation, (d) capacity
Examined Lives 121
for enjoyment, and (e) improved self-esteem. The substance of the oral report card
is further elaborated in the final discharge report. These documents were given to
a student who was naive as to subject assignment to either the self-examined or
the adjusted group. The student was instructed to consult the oral report card and
the final report of each subject and, using a prepared cumulative weighted scale
schema (see Table 2), assign an overall rating of acceptance of the disability, as
could be ascertained from these documents.
In addition to the subjects' self-ratings in the six wellness areas and the naive
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Statistical Analyses
To test whether the six areas of wellness in which subjects were asked to rate
themselves were redundant, Spearman rho correlations were performed on the
ratings in each area. The ratings of the self-examined and the adjusted subjects
were compared via Mann-Whitney U test. Due to the nature of the data and/or the
small sample size in each group, the Mann-Whitney U test was also used to test
whether the two groups differed in terms of the age of the subjects upon entry into
the program, their assigned cumulative weighted scale scores in acceptance of the
disability, their overall vocational index (as rated at present), and the psychomet-
ric test scores obtained before discharge from our program. Finally, to test
whether the level of acceptance of a person's disability, at the point of discharge
from our program, correlated with that person's subsequent vocational success,
RESULTS
Categorical reasoning
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DISCUSSION
does not mean a passive resignation to an unfortunate state (and the loss of one's
This document is copyrighted by the American Psychological Association or one of its allied publishers.
some satisfaction from their new, i.e., different life) misses the bigger picture of
rehabilitation. It also deprives rehabilitation professionals of a meaningful way to
determine when and whether the person has reached full rehabilitation potential.
The second point, a corollary to the first, is that looking beyond the present
situation to the time when the promotion of wellness becomes a practical concern
of health delivery systems, we should begin to seriously think about developing
wellness targets in the field of neuropsychological rehabilitation, as well as
objective and valid tools capable of measuring progress toward those targets of
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wellness.
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